PROJECT SUMMARY Cardiovascular disease (CVD), including heart disease and stroke, is our nation?s costliest and most devastating chronic disease, and is fraught with diagnostic error. Despite ground-breaking progress in addressing CVD through years of clinical and biological research, errors in the diagnosis, treatment, and communication of CVD disproportionately impact women. Women are nearly twice as likely as men to receive the wrong initial diagnosis following a heart attack and 30% more likely to have stroke symptoms misdiagnosed in the emergency department (ED). Even when accurately diagnosed, women are less likely to receive timely evidence-based treatments. The National Academy of Medicine report Improving Diagnosis in Healthcare defined diagnostic error as ?the failure to (a) establish an accurate and timely explanation of the patient?s health problem(s) or (b) communicate that explanation to the patient?. On every dimension of that definition, women with CVD fare worse than men and the combination of gender and race is even more lethal. Transdisciplinary teams leveraging systems engineering, using novel tactics and rigorous evaluation techniques are positioned to successfully mitigate this complex problem. Our Patient Safety Learning Laboratory (PSLL) will address Re-engineering for Accurate, Timely, and Communicated Diagnosis of Cardiovascular Diseases in Women: the (DREAM) Lab. We will apply a mixed-methods systems engineering approach to understand the complex interplay of factors contributing to CVD diagnostic error in women in the ambulatory care setting, and co-design and evaluate adaptive solutions. Our population health approach will evaluate factors including but not limited to the physical environment, social and economic determinants, clinical care, health information technology, and health behaviors. The DREAM Lab will: a. Identify the contributing factors leading to diagnostic errors and inappropriate clinical management of CVD in women and develop pragmatic performance and improvement measures. b. Propose, prioritize, and co-design human-centered solutions to mitigate diagnostic risk. c. Evaluate the structure, process, and outcome effects of human-centered solutions on CVD diagnosis, clinical management, and communication in simulated and clinical environments. The proposed work sets up a clear pathway toward clinical implementation. By systematically evaluating human-centered solutions in a simulated environment with input from practicing clinicians and patients as the end-users, followed by pilot testing promising solutions in the clinical environment, we provide operationally ready solutions. The DREAM Lab?s impact, particularly for vulnerable patients disproportionately impacted by heart attacks and stroke, has the potential to influence broad-scale change and disrupt the status-quo, yielding significant improvements in care cost, quality, experience, and value for women and the healthcare system.